Coronary Vasomotor Dysfunction Is Associated With Cardiovascular Events in Patients With Nonobstructive
Yoshihisa Kanaji1, Ali Ahmad2, Jaskanwal Deep Singh Sara2
1Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan.
Insights
Coronary vasomotor dysfunction (CVDys) phenotypes are linked to worse outcomes in patients with angina and nonobstructive coronary artery disease (ANOCA). Both endothelium-dependent and independent microvascular dysfunction predict adverse cardiac events.
Area of Science:
- Cardiology
- Vascular Biology
- Clinical Medicine
Background:
- Coronary vasomotor dysfunction (CVDys) is a complex condition affecting coronary artery function.
- Classifying CVDys based on anatomical and functional mechanisms is crucial for understanding its impact.
- Patients with angina and nonobstructive coronary artery disease (ANOCA) often present diagnostic challenges.
Purpose of the Study:
- To investigate the association between distinct CVDys phenotypes and clinical outcomes in ANOCA patients.
- To determine the prognostic value of different types of coronary endothelial and non-endothelial dysfunction.
- To identify specific CVDys patterns that predict major adverse cardiac and cerebrovascular events.
Main Methods:
- Coronary reactivity testing using intracoronary Doppler guidewire in 1,196 ANOCA patients.
- Assessment of endothelium-dependent and -independent microvascular and epicardial coronary function.
- Definition of dysfunction based on coronary blood flow, diameter changes, coronary flow reserve, and response to acetylcholine and nitroglycerin.
- Follow-up for major adverse cardiac and cerebrovascular events (MACE) over a median of 6.3 years.
Main Results:
- Prevalence of CVDys varied: 51.8% endothelium-dependent microvascular dysfunction, 24.5% endothelium-independent microvascular dysfunction, 47.4% endothelium-independent epicardial coronary dysfunction, and 25.4% endothelium-dependent epicardial coronary dysfunction.
- Patients with endothelium-dependent microvascular dysfunction (19.5%), endothelium-dependent epicardial coronary dysfunction (19.7%), or endothelium-independent microvascular dysfunction (22.2%) had significantly higher MACE rates compared to those without.
- Reduced coronary flow reserve and impaired endothelium-dependent microvascular response to acetylcholine were independent predictors of MACE.
Conclusions:
- Specific CVDys phenotypes are differentially associated with adverse outcomes in ANOCA patients.
- Endothelium-dependent and endothelium-independent microvascular function provide independent prognostic information.
- Targeting and understanding these specific functional deficits may improve risk stratification and management in ANOCA.
Background:
Coronary vasomotor dysfunction (CVDys) can be comprehensively classified on the basis of anatomy and functional mechanisms.
Objectives:
The aim of this study was to evaluate the association between different CVDys phenotypes and outcomes in patients with angina and nonobstructive coronary artery disease (ANOCA).
Methods:
Patients with ANOCA who underwent coronary reactivity testing using an intracoronary Doppler guidewire to assess microvascular and epicardial coronary endothelium-dependent and endothelium-independent function were enrolled. Endothelium-dependent microvascular and epicardial coronary dysfunction were defined as a <50% change in coronary blood flow in response to intracoronary acetylcholine (Ach) infusion and a <-20% change in coronary artery diameter in response to Ach. Endothelium-independent microvascular and epicardial coronary dysfunction were defined as coronary flow reserve < 2.5 during adenosine-induced hyperemia and change in cross-sectional area in response to intracoronary nitroglycerin administration < 20%. Major adverse cardiac and cerebrovascular events (cardiovascular death, nonfatal MI, heart failure, stroke, and late revascularization) served as clinical outcomes.
Results:
Among the 1,196 patients with ANOCA, the prevalence of CVDys was 24.5% and 51.8% among those with endothelium-independent and endothelium-dependent microvascular dysfunction, respectively, and 47.4% and 25.4% among those with endothelium-independent and endothelium-dependent epicardial coronary dysfunction, respectively. During 6.3 years (Q1-Q3: 2.5-12.9 years) of follow-up, patients with endothelium-dependent microvascular dysfunction, endothelium-dependent epicardial coronary dysfunction, or endothelium-independent microvascular dysfunction showed significantly higher event rates compared with those without (19.5% vs 12.0% [P < 0.001], 19.7% vs 14.6% [P = 0.038] and 22.2% vs 13.8% [P = 0.001], respectively). Coronary flow reserve (HR: 0.757; 95% CI: 0.604-0.957) and percentage change in coronary blood flow in response to Ach infusion (HR: 0.998; 95% CI: 0.996-0.999) remained significant predictors of major adverse cardiac and cerebrovascular event after adjustment for conventional risk factors.
Conclusions:
CVDys phenotype is differentially associated with worse outcomes, and endothelium-dependent and endothelium-independent microvascular function provide independent prognostic information in patients with ANOCA.
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